关于肛瘘,第一,肛瘘是肛周细菌感染的慢性阶段,好发于男性,常见于便稀的患者,所以保持大便正常一定程度上可以避免肛瘘的发生。第二,肛瘘还是建议早期手术治疗,虽然有症状轻微的肛瘘患者带瘘生存,但仍存在很多潜在的风险。
大便干燥是肛裂的诱发因素,不是肛裂的根本原因。肛裂是指肛管皮肤粘膜深及全层的裂开,形成梭形溃疡的病变。大多发生在肛管后壁正中部,少数在前壁正中部。肛裂的典型症状是大便时和便后肛门疼痛、常伴有少量出血。肛裂疼痛的特点是典型的周期性疼痛。.即:初有便意时即感到轻微的不适和疼痛,排便时粪便通过肛管,肛管扩张时产生撕裂样的疼痛,便后稍微有短暂的缓解间歇期,约5分钟左右,再次因扩约肌痉挛而出现疼痛加重,持续时间可达1小时之久,甚至可达数小时,患者坐卧不安十分痛苦,以后逐渐缓解。再次排便时疼痛周而复始,使患者对排便产生畏惧心理而忍便。因为疼痛,患者刻意减少排便次数,延迟排便时间,使粪便更加秘结,加重了对肛管的损伤,形成恶性循环:疼痛-括约肌痉挛-肥厚-肛门狭窄-延迟排便-大便干硬-进一步裂伤。因此肛门括约肌肥厚痉挛肛管狭窄才是肛裂的病因。
首先要知道在那些情况下痔疮可以保守治疗,症状不重的Ⅰ度、Ⅱ度内痔;炎性外痔。Ⅰ度、Ⅱ度内痔主要表现为便时肛门出鲜红色血,一般无痛。炎性外痔是有炎症的外痔,可采取保守治疗。但对于出血较重,甚至造成贫血的应尽早手术治疗。Ⅲ度以上内痔及混合痔,,因其发作频繁,保守治疗效果差。外痔皮赘不可能因保守治疗而变小。保守治疗的方法分为口服用药,局部用药,局部理疗。口服用药:迈之灵,痔根断等,主要作用是改善痔疮局部血流,增强痔血管弹性等,特别提醒:除了炎性外痔以外,应避免口服抗生素,因为其可引起肠道菌群失调,引起大便干结,大便干结会加重痔疮。肛门局部应用的药膏和栓剂,有马应龙痔疮膏,太宁膏等,栓剂有肛泰栓,泰宁栓等。可起到保护粘膜,消炎止痛效果。局部理疗:主要是指温水坐浴,或中药坐浴,可起到消炎止痛效果,减轻水肿。保守治疗期间,,在痔脱出甚至嵌顿时应当及时复位,并进行适当缩肛锻炼,否则脱出太久或嵌顿可能出现脱出痔块越来越大,嵌顿的痔块出现血栓,坏死及出血,造成难以忍受的疼痛。有的病人在出现痔嵌顿后,不仅不敢自行复位,因为肛门有坠胀感,不断地去蹲厕所,致使嵌顿痔水肿、脱出加重。如果是一个真正的肛肠专家,他会很负责地告诉您,所有的痔疮药都治标不治本,只是在痔疮发作的时候能够起到消炎、止痛、止血的作用,并不能保证今后不再复发。在每年一度的全国肛肠专业学术会上,至今为止,还没听说过哪一种痔疮药能够取代手术治疗。痔疮药没有好坏之分,因此,没有必要花大价钱去买什么进口特效药。国产的痔疮药的疗效并不次于进口药,我国在肛肠疾病的治疗方面技术还是领先的。到肛肠外科手术治疗的患者,有几个不是用遍了国内外的痔疮药,最后无奈才来医院做手术的?如果用痔疮药真的好使,国内哪能还有这么多的肛肠医院?
治疗组:药用蒲公英 30g,紫花地丁 20g,金银花 25g,黄柏10g,红花 15g,苦参 15g,五倍子 10 g,艾叶 10g,乳香 10g,没药10g,川椒 30g,百部 30g,蝉蜕 30g。瘙痒重者加白鲜皮 20g,糜烂、渗出多者加马齿苋 20g。药物放入砂锅内浸泡、煮沸30min,倒入盆内先以药液蒸汽熏洗肛门 ,待药液温度适宜时坐浴 20min,早晚各 1次,每天 1剂 , 7天为一疗程 ,共治 1~3个疗程。
痔动脉结扎术(多普勒引导下)手术过程:利多卡因局部浸润麻醉或骶麻,患者左侧卧位。Doppler肛门镜插入直肠,探头在齿线上2-3CM旋转探头寻找动脉,用2-0可吸收缝线“8”字缝合。一圈后肛门镜退后0.5cm重复一遍,保证缝线距离齿线至少0.5cm。有皮赘者剪除。 临床疗效:根据相关医疗机构2007年初的临床报告,共22例痔动脉结扎患者,在Doppler引导下发现并结扎4-8条痔动脉,结果21例主诉症状消失,1例明显好转,1例20年便秘在术后消失。4例术后大便时间较术前大便时间有明显缩短。没有发现肛瘘、肛门狭窄或失禁病例。 专家评述:多普勒引导下的痔动脉结扎术是一种微创手术,手术病人大多不需要止痛药,恢复日常生活快,因为没有真正的手术伤口,创伤很小,明显缩短住院时间。DGHAL术治疗机理: A:结扎后动脉血流减少,肛垫内压力降低,痔萎缩,出血和疼痛停止。有利于痔萎缩最终决定垂脱减少,整个过程支持“高压肛垫理论”。 B:在术中缝合时直接将直肠黏膜及痔上极直接缝合固定在肌层上,阻止了肛垫的下移。 C:通过缝扎阻断出血血管。适应症:1 1;2度的内痔 2内痔出血-立竿见影痔动脉的反应性扩张充血,应当是肛垫损伤的反应,痔动脉结扎后肛垫萎缩,会不会引起其他问题,如感觉功能减退。因为此手术方法也才是近3-5年的事。有待于长期随访。需要询证医学的支持。
便秘是由多种病因引起的常见病症。患者常有粪便干结、排便困难或不尽感,在不用通便药时,完全排空粪便的次数显著减少等。 流行病学:各国关于便秘的调查资料,方法不一。美国人群中便秘患病率的范围在2%到28%之间,我国北京、天津和西安地区对60岁以上老年人的调查显示,我国60岁以上老年人的慢性便秘比率高达15%-20%。而对北京地区18-70岁成年人进行的一项随机、分层、分级调查表明,慢性便秘的发病率为6.07%,女性是男性的4倍以上,且精神因素是高危因子之一。 便秘的危害性:随着饮食结构的改变及精神心理和社会因素的影响,便秘已严重影响了现代人生活质量;且在结肠癌、肝性脑病、乳腺疾病、早老性痴呆等疾病的发生中有重要的作用;在急性心肌梗塞、脑血管意外等症时便秘可导致生命意外;部分便秘和肛肠疾病,如痔、肛裂等均有密切的关系。因此,早期预防和合理治疗便秘,将会大大减轻便秘带来的严重后果和社会负担。 建立便秘诊治流程的必要性:考虑到临床上受便秘困扰的患者如此之多,明确诊断常需要较高费用,因此寻找有效的诊治便秘的途径就显得极为重要。制定适合于我国的便秘诊治流程,使其符合中国现状的、简单有效的、具有可操作性的便秘诊治流程,以便更有效地利用有限的卫生资源,这必将使整个社会受益。以下将简述便秘的病因、检查方法及诊治,复习罗马II有关便秘的诊断标准和国际便秘诊治流程,并提出经广泛酝酿、研讨的我国慢性便秘的诊治流程及其原则(草案)。希望在会上再次得到深入的讨论和共识。 一、便秘的病因、检查方法评价和诊治 健康人排便习惯多为一日1-2次或1-2日1次排便,粪便多为成形或为软便(如Bristol类型中的4型和5型),少数健康人的排便次数可达3次/日,或3日1次。粪便呈半成形或呈腊肠样硬便(如Bristol类型中的6型和3型)。正常排便需要肠内容物以正常速度通过各段,及时抵达直肠,并能刺激直肠肛门,引起排便反射,排便时盆底肌群协调活动,完成排便。以上任一个环节的故障,均可能引起便秘。因而对便秘患者应了解引起排便故障的环节、机制及有关的病因和诱因,方可能制定合理的治疗方案。 (一)、慢性便秘的病因 慢性便秘有功能性和器质性病因。器质性病因可以由胃肠道疾病、累及消化道的系统性疾病如糖尿病、硬皮病、神经系统疾病等,许多药物可以引起便秘,如下:肠管器质性病变如肿瘤、炎症或其他原因引起的肠腔狭窄或梗阻。 1.直肠、肛门病变:直肠内脱垂、痔病、直肠前膨出、耻骨直肠肌肥厚、耻直分离、盆底病等。 2.内分泌或代谢性疾病:如糖尿病肠病、甲状腺功能低下、甲状旁腺疾病等。 3.神经系统疾病:如中枢性脑部疾患、脑卒中、多发硬化、脊髓损伤以及周围神经病变 4.肠管平滑肌或神经元性病变 5.结肠神经肌肉病变:假性肠梗阻、先天性巨结肠、巨直肠等。 6.精神及心理障碍 7.药物性因素:铝抗酸剂、铁剂、阿片类、抗抑郁剂、抗帕金森氏病药、钙通道拮抗剂、利尿剂以及抗组胺药等。 (二)、慢性便秘的检查方法及评估 慢性便秘的诊断方法包括病史、体格检查、有关化验、影像学检查和特殊检查方法。 病史:详细了解病史,包括有关便秘的症状及病程、胃肠道症状、伴随症状和疾病,以及用药情况常能提供十分重要的信息。 注意 (1)、有无报警症状(如便血、贫血、消瘦、发热、黑便、腹痛等),(2)、便秘症状特点(便次、便意、是否困难或不畅以及粪便性状),(3)、伴随的胃肠道症状,(4)、和病因有关的病史,如肠道解剖结构异常或系统疾病,及药物因素引起的便秘,(5)、精神及心理状态及社会因素。 一般检查方法: (1)、肛门直肠指检常能帮助了解粪便嵌塞、肛门狭窄、痔病或直肠脱垂、直肠肿块等症,也可了解肛门括约肌的功能状况。 (2)、血常规、便常规、粪便隐血试验是排除结、直肠、肛门器质性病变的重要而又简易的常规。必要时进行有关生化和代谢方面的检查。(3)、对可疑肛门、直肠病变者,直肠镜或乙状结肠镜/结肠镜检查,或钡剂灌肠能直视观察肠道或显示影像学资料。 特殊检查方法:对慢性便秘患者,可以酌情选择以下有关检查。 1.胃肠通过试验(gastrointestinal transit test, GITT): 常用不透X线标志物,早餐时随试验餐吞服含有20个标志物,相隔一定时间后(例如在服标志物后24h、48h、72h)拍摄腹片一张,计算排出率。正常情况下服标志物后48-72h时,大部分标志物已排出。根据腹片上标志物的分布,有助于评估便秘是慢传输型或是出口梗阻型,为一简易、可行的方法。 2.肛门直肠测压(anorectal manometry ARM):常用灌注式测压(同食管测压法),分别检测肛门括约肌静息压、肛门外括约肌的收缩压和力排时的松弛压、直肠内注气后有无肛门直肠抑制反射出现,还可以测定直肠的感知功能和直肠壁的顺应性等。有助于评估肛门括约肌和直肠有无动力和感觉功能障碍。 3.结肠压力监测:将传感器放置到结肠内,在相对生理的情况下连续24-48h监测结肠压力变化。对确定有无结肠无力,对治疗有指导意义。 4.气球排出试验(balloon expulsion test BET):在直肠内放置气囊,充气或充水,并令受试者将其排出。可作为有无排出障碍的筛选试验,对阳性的患者,需要作进一步检查。 5.排粪造影(barium defecography BD):将模拟的粪便灌入直肠内,在放射线下动态观察排便过程中肛门和直肠的功能变化,可了解患者有无伴随的解剖异常,如直肠前膨出、肠套叠等。 6.其它:如盆底肌电图,能帮助明确病变是否为肌源性。阴部神经潜伏期测定能显示有无神经传导异常。肛门超声内镜检查可以了解肛门括约肌有无缺损等。 (三)、慢性便秘的诊断 对慢性便秘患者的诊断应包括:便秘的病因(和诱因)、程度、及便秘类型。如能了解和便秘有关的累及范围(结肠、肛门直肠、或伴上胃肠道)、受累组织(肌病或神经病变)、有无局部结构异常及其和便秘的因果关系。则对制定治疗和预测疗效均非常有用。以下分述慢性便秘的严重程度及便秘类型。 慢性便秘的严重程度:可将便秘分为轻、中、重三度。轻度指症状较轻,不影响生活,经一般处理能好转,无需用药或少用药。重度指便秘症状持续,患者异常痛苦,严重影响生活,不能停药或治疗无效。中度则鉴于两者之间。所谓的难治性便秘常常是重度便秘,可见于出口梗阻型便秘、结肠无力以及重度便秘型肠易激综合征(IBS)等。 慢性便秘的类型:分为慢传输型、出口梗阻型和混合型。IBS的便秘型是一类和腹痛或腹胀有关的便秘,同时,也可能有以下各类型的特点。 1、慢传输型便秘(slow transit constipation, STC) 有以下表现: (1)、常有排便次数减少,少便意,粪质坚硬,因而排便困难。(2)、肛直肠指检时无粪便或触及坚硬的粪便,而肛门外括约肌的缩肛和力排功能正常。 (3)、全胃肠或结肠通过时间延长。 (4)、缺乏出口梗阻型便秘的证据,如气球排出试验正常,肛门直肠测压显示正常。 2、出口梗阻型便秘(outlet obstructive constipation, OOC) 可有以下表现: (1)、排便费力、不尽感或下坠感,、排便量少,有便意或缺乏便意。 (2)、肛直肠指检时直肠内存有不少泥样粪便,力排时肛门外括约肌呈矛盾性收缩。 (3)、全胃肠或结肠通过时间显示正常,多数标志物可潴留在直肠内。 (4)、肛门直肠测压时显示力排时肛门外括约肌呈矛盾性收缩等或直肠壁的感觉阈值异常。 3、混合型便秘:具备以上1和2的特点。 以上三类适合于功能性便秘的类型,也适合于其他病因引起的慢性便秘。例如,糖尿病、硬皮病合并的便秘以及药物引起的便秘多是慢传输型便秘。肠易激综合征便秘型的特点是排便次数少,排便常常艰难,排便、排气后腹痛或腹胀缓减,可能有出口功能障碍合并慢通过型便秘,如能结合有关功能检查,则能进一步证实其临床类型。 (四)、慢性便秘的治疗 其治疗原则是根据便秘轻重、病因和类型,进行综合治疗,恢复正常的排便习惯和排便生理。 1、一般治疗:加强排便的生理教育,建立合理的饮食习惯(如增加膳食纤维含量,增加饮水量)及坚持良好的排便习惯,同时应增加活动。 2、药物治疗:选用适当的通便药物。选择药物应以少有毒、副作用及药物依赖为原则,常选用的如膨松剂(如麦麸、欧车前等)和渗透性通便剂(如福松、乳果糖)。应用福松治疗功能性便秘的随机对照观察显示,对增加排便次数和改善粪便性状疗效均称好。对慢传输型便秘,还可加用促动力剂,如西沙必利或莫沙必利等。需要注意的是,对慢性便秘患者,应避免长期应用或滥用刺激性泻剂。多种中成药具有通便作用,但需注意长期服用中成药治疗慢性便秘时,应注意其内的成分及其副作用。对粪便嵌塞的患者,清洁灌肠一次或结合短期使用刺激性泻剂以解除嵌塞。解除后,再选用膨松剂或渗透性药物,保持排便通畅。开塞露和甘油栓有软化粪便和刺激排便的作用。复方角菜脂酸能对治疗痔源性便秘有效。 3.心理疗法与生物反馈:中、重度的便秘患者常有焦虑甚至抑郁等心理因素或障碍的表现,应予以认知治疗,使患者消除紧张情绪。生物反馈疗法适用于功能性出口梗阻型便秘。 4.外科治疗:如经严格的非手术治疗后仍收效不大,且各种特殊检查显示有明确的病理解剖和确凿的功能性异常部位,可考虑手术治疗。外科手术的适应证包括继发性巨结肠、部分结肠冗长、结肠无力、重度的直肠前膨出症、直肠内套叠、直肠粘膜内脱垂等。但应注意有无严重的心理障碍,有无结肠以外的消化道异常,术前需要进行预测疗效。 三、国际上慢性便秘的诊断标准及诊治流程 1999年9月国际Rome II协作委员会在Rome I的基础上,制订了Rome II功能性胃肠疾病的一系列诊断标准 (Gut1999, 45:Suppl II)。尽管目前各国消化学界对便秘的认识不尽一致,但仍以Rome II诊断标准为基础,结合各国的实际情况制订本国的诊治流程。以下介绍有关Rome II的慢性便秘、功能性便秘、盆底排便障碍及IBS便秘型的诊断标准,并介绍近来美国在Rome II标准的基础上制订的《美国便秘治疗指南》的要点。 (一)、罗马II有关便秘的诊断标准: 慢性便秘(chronic constipation):罗马II对慢性便秘的诊断标准是:具备在过去12个月中至少12周连续或间断出现以下2个或2个以上症状: (1) >1/4的时间有排便费力,(2) >1/4的时间有粪便呈团快或硬结,(3) >1/4的时间有排便不尽感,(4) >1/4的时间有排便时肛门阻塞感或肛门直肠梗阻,(5) >1/4的时间有排便需用手法协助,(6) >1/4的时间有每周排便<3次。不存在稀便,也不符合IBS的诊断标准。 功能性便秘(functional constipation):根据罗马II诊断标准,功能性便秘除符合以上诊断标准外,同时需除外肠道或全身器质性病因以及药物因素所致的便秘。 盆底排便障碍(pelvic floor dyssynergia):罗马II关于盆底排便障碍的诊断标准是指除了符合以上功能性便秘的罗马II诊断标准外,还需符合以下几点,即: (1)、必须要有肛门直肠测压、肌电图或X线检查的证据,表明在反复作排便动作时,盆底肌群不合适的收缩或不能放松,(2)、力排时直肠能出现足够的推进性收缩,(3)、并有粪便排出不畅的证据。 便秘型肠易激综合征(irritable bower syndrome, constipation-predominant, 便秘型IBS):肠易激综合征是以腹部不适或疼痛并有排便习惯改变和排便异常为特征的功能性肠病,X线钡剂灌肠检查或结肠镜检查无病变,也无系统疾病的证据。便秘型IBS是指首先符合IBS标准的基本点,即在过去12个月内至少存在12周(不一定连续)有腹痛或腹部不适症状,伴以下3条中2条者: (1)、便后上述症状消失,(2)、上述症状出现时伴有大便次数的改变,或 (3)、伴有大便性状改变。并有以下表现的支持,即有(1)、便次少于3次/周、(2)大便性状呈块状或硬结、(3)、排便时费力、排便不尽感3项中的至少1项, 同时不具备 (1)、便次大于3/日,(2)、稀便,(3)、排便紧迫感中的任何一项;或者必须符合这3项中至少2项,同时可具备 (1)、便次大于3/日,(2)、稀便 (3)、排便紧迫感中的一项。 (二)、美国关于慢性便秘的诊治流程的要点: 美国提出的慢性便秘流程的要点是根据病史和体格检查,结合有关的实验室检查,并首先提出试验性治疗,对难治性便秘患者,再进行钡剂排粪造影及有关动力功能检查,根据便秘类型,进行相应治疗。并将流程分为诊断步骤和根据不同的便秘类型提出相应的治疗步骤。根据初步评定结果,将便秘的诊断分为6种情况,即 (1)、IBS便秘型,(2)、慢传输型便秘,(3)、直肠出口梗阻型,(4)、以上(2)和(3)并存,(5)、机能性便秘(功能性梗阻或药物副作用),(6)、继发于系统疾病的便秘。 四、我国便秘流程及其原则 便秘有程度、类型以及病因和诱因之分,因而,对便秘患者需要作分级分层的诊治分流,这样的诊治流程有利于对患者进行积极有效的诊治,并产生合理的费效比。 (一)、诊治流程 临床上,为了做到对便秘患者进行有效的分层(报警与否)、分级(程度)分流诊治,需要评估引起便秘的病因和诱因、便秘的类型以及程度。对多数患者来说,通过详细的病史和查体,可了解其病因、便秘的类型,进行经验治疗;对有报警征象、或怀疑有器质性疾病引起的便秘时,应进一步检查,除外或证实有无器质性疾病,尤其是结肠肿瘤;对确定是器质性疾病的便秘患者,除了病因治疗外,同时也需要根据便秘的特点,判断便秘类型,进行相应的治疗;对经验治疗或经检查未证实是器质性便秘的病例,进一步的检查可以确定便秘的类型,再进行相应的治疗;对少数难治性便秘患者,一开始就进行有关的便秘类型检查,甚至更详细的检查,以便确定治疗手段。 (二)、诊治原则 我国便秘诊治的原则包括: 1、详细了解病史和查体,是选择便秘流程的重要基础。对多数便秘患者,尽量用非侵入性方法,判断便秘类型,根据经验治疗疗效,验证临床推断。 2、便秘类型是选择治疗方法的重要依据。无论是经验治疗、或进一步检查后的治疗,均强调针对不同的便秘类型,予以相应的治疗对策。 3、提出对有报警征象的便秘患者,强调病因调查,而对难治性便秘又缺乏报警征象者,强调确定便秘类型的重要性。 4、接受各种检查手段的比例:对多数便秘来说,以经验治疗为主,对难治性便秘则应进一步检查,少数患者尤其是需要外科手术的患者,需要更深入检查。 5、流程中几条路线可以相互穿行。如对经验治疗疗效不佳者,进一步检查以了解病因和类型,而一开始经检查后未发现器质性性病变时,可回到了解便秘特征作出便秘类型,或进一步进行有关便秘类型的检查后进行治疗等。 (三)、经验治疗的依据 慢性便秘常见的表现有以下几类: 1、便意少,便次也少:此类便秘可见于慢通过型和出口梗阻型便秘。前者是由于通过缓慢,使便次和便意均少,但间隔一定时间仍能出现便意,粪便常干硬,用力排便有助於排出粪便。而后者常常是感觉阈值增高,不易引起便意,因而,便次少,而粪便不一定干硬。对这些患者可试用膨松剂或渗透剂,增加粪便含水量,增加软度和体积,刺激结肠蠕动,也能增加对直肠粘膜的刺激。同时应定时排便。 2、排便艰难,费力:突出表现为粪便排出异常艰难,也见于两种情况,以出口梗阻性便秘更为多见。患者力排时,肛门外括约肌呈现矛盾性收缩,以致排便困难。这种类型的便次不一定少,但费时费力。如伴有腹肌收缩无力,则更加重排便难度。第二种情况是由于通过缓慢,粪便内水分过多被吸收,粪便干结,尤其是长时间不排便,使干硬的粪便排出异常困难,可发生粪便嵌塞。这类便秘也可试用膨松剂或渗透剂,使粪便变软,便于排出,有时需结合灌肠治疗。如粪便软化后依然难以排出时,则提示为出口梗阻性便秘。这一类患者需要指导排便方式,必要时进行生物反馈治疗。 3、排便不畅:常有肛门直肠内阻塞感,排便不畅。虽频有便意,便次不少,即便费力也无济于事,难有畅通的排便。可伴有肛门直肠刺激症状,如下坠、不适等。此类患者常有感觉阈值降低,直肠感觉高敏,或伴有直肠内解剖,如直肠内套叠以及内痔等。个别病例的直肠感觉阈值升高,也出现类似症状,可能与合并肛门直肠局部解剖改变有关。这部分患者的治疗需要提高感觉阈值,减少排便次数,治疗肛门直肠局部病变,如痔源性便秘的局部处理。 4、便秘伴有腹痛或腹部不适:常见于IBS便秘型,常排便后症状缓解。 以上便秘类型不仅见于功能性便秘,也见于IBS便秘型(也可能有以上各类型的表现)。同时对于器质性疾病例如糖尿病引起的慢性便秘,以及药物引起的便秘,均可以有以上类型的表现。应注意分析。此外,还常有以上各种情况的组合。 (三)、有关病因学检查 影像学或内镜检查,必要时结合病理学检查确定有无肠道器质性疾病,如怀疑糖尿病、内分泌病、结缔组织病、和神经系统疾病时,应作相应的生化和免疫检查。 (四)、确定便秘类型的常用方法:用于判断便秘类型的常用检查方法有胃肠通过试验和肛门直肠测压,提出肛门直肠指检可帮助诊断。 1、胃肠通过试验:建议在至少停用有关药物48h后服用不透X线标志物20个后,拍摄腹片一张(正常时多数标志物已经抵达直肠或已经排出),选择48h摄片的目的是有可能观察到此时的标志物分布,如多数已经集中在乙状结肠和直肠区域之内或尚未达到此区域,那末则分别提示通过正常或延缓,如在72h再拍摄一张,若多数标志物仍未抵达乙状结肠和直肠或仍在乙状结肠、直肠,则分别支持慢通过便秘或出口梗阻性便秘。胃肠通过试验是一种简易方法,可以推广应用。如果延长到5-6日拍片一张,其准确性可能增高,但可行性较差,因为多数患者难以坚持而自行用泻药。试验的敏感性降低,尤其是难以判断便秘类型,除非是作系列摄片。 2、肛门直肠测压:能提供有无引起便秘的肛门直肠局部机制,例如在力排时肛门外括约肌出现矛盾性收缩,提示有出口梗阻性便秘;向直肠气囊内注气后,如肛门直肠抑制反射缺如,则提示有Hirschsprung’s disease;以及直肠壁粘膜对气囊内注气后引起的便意感、最大耐受限度的容量等,能提供直肠壁的排便阈值是否正常。 3、肛门直肠指检:这里强调,肛门直肠指诊不仅是检查有无直肠癌的重要的方法,也是判断有无出口梗阻性便秘的常用、简易手法。尤其是增强的括约肌张力,力排时括约肌不能有所松弛,反而更加收缩紧张,提示长期极度费力排便,导致括约肌肥厚,同时在力排时处于矛盾性收缩。 (五)、有关难治性便秘特殊性检查:例如,重度慢通过便秘对各种治疗无效者,常提示是结肠无力,如24h结肠压力监测缺乏特异的推进性收缩波(Specialized propagating pressure wave,SPPW),提示需要手术治疗。排粪造影能动态观察肛门直肠的解剖和功能变化。肛门测压结合超声内镜检查,同时显示肛门括约肌有力学上的缺失和解剖上的薄弱。军为肛肠外科手术提供重要线索。少数便秘需要分辨病变是肌原性或是神经原性,需要检查会阴神经潜伏期或肌电图。对伴有明显焦虑和抑郁的患者,应作有关的调查。What is constipation?Constipation means different things to different people. For many people, it simply means infrequent stools. For others, however, constipation means hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after a bowel movement. The cause of each of these "types" of constipation probably is different, and the approach to each should be tailored to the specific type of constipation. Constipation also can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel syndrome (IBS). At the extreme end of the constipation spectrum is fecal impaction, a condition in which stool hardens in the rectum and prevents the passage of any stool.The number of bowel movements generally decreases with age. Ninety-five percent of adults have bowel movements between three and 21 times per week, and this would be considered normal. The most common pattern is one bowel movement a day, but this pattern is seen in less than 50% of people. Moreover, most people are irregular and do not have bowel movements every day or the same number of bowel movements each day.Medically speaking, constipation usually is defined as fewer than three bowel movements per week. Severe constipation is defined as less than one bowel movement per week. There is no medical reason to have a bowel movement every day. Going without a bowel movement for two or three days does not cause physical discomfort, only mental distress for some people. Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to cancer.It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon). Constipation also requires an immediate assessment if it is accompanied by worrisome symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary loss of weight. In contrast, the evaluation of chronic constipation may not be urgent, particularly if simple measures bring relief.What causes constipation?Theoretically, constipation can be caused by the slow passage of digesting food through any part of the intestine. More than 95% of the time, however, the slowing occurs in the colon.MedicationsA frequently over-looked cause of constipation is medications. The most common offending medications include:Narcotic pain medications such as codeine (for example, Tylenol #3), oxycodone (for example, Percocet), and hydromorphone (Dilaudid); Antidepressants such as amitriptyline (Elavil) and imipramine (Tofranil) Anticonvulsants such as phenytoin (Dilantin) and carbamazepine (Tegretol) Iron supplements Calcium channel blocking drugs such as diltiazem (Cardizem) and nifedipine (Procardia) Aluminum-containing antacids such as Amphojel and BasaljelIn addition to the medications listed above, there are many others that can cause constipation. Simple measures (for example, increasing dietary fiber) for treating the constipation caused by medications often are effective, and discontinuing the medication is not necessary. If simple measures don't work, it may be possible to substitute a less constipating medication. For example, a nonsteroidal antiinflammatory drug (for example, ibuprofen) may be substituted for narcotic pain medications. Additionally, one of the newer and less constipating anti-depressant medications [for example, fluoxetine (Prozac)] may be substituted for amitriptyline and imipramine.HabitBowel movements are under voluntary control. This means that the normal urge people feel when they need to have a bowel movement can be suppressed. Although occasionally it is appropriate to suppress an urge to defecate (for example, when a bathroom is not available), doing this too frequently can lead to a disappearance of urges and result in constipation.DietFiber is important in maintaining a soft, bulky stool. Diets that are low in fiber can, therefore, cause constipation. The best natural sources of fiber are fruits, vegetables, and whole grains.LaxativesOne suspected cause of severe constipation is the over-use of stimulant laxatives [for example, senna (Senokot), castor oil, and certain herbs]. An association has been shown between the chronic use of stimulant laxatives and damage to the nerves and muscles of the colon, and it is believed by some that the damage is responsible for the constipation. It is not clear, however, whether the laxatives have caused the damage or whether the damage existed prior to the use of laxatives and, indeed, has caused the laxatives to be used. Nevertheless, because of the possibility that stimulant laxatives can damage the colon, most experts recommend that stimulant laxatives be used as a last resort after non-stimulant treatments have failed.Hormonal disordersHormones can affect bowel movements. For example:Too little thyroid hormone (hypothyroidism) and too much parathyroid hormone (by raising the calcium levels in the blood) can cause constipation. At the time of a woman's menstrual periods, estrogen and progesterone levels are high and may cause constipation. However, this is rarely a prolonged problem. High levels of estrogen and progesterone during pregnancy also can cause constipation.Diseases that affect the colonThere are many diseases that can affect the function of the muscles and/or nerves of the colon. These include diabetes, scleroderma, intestinal pseudo-obstruction, Hirschsprung's disease, and Chagas disease. Cancer or narrowing (stricture) of the colon that blocks the colon likewise can cause a decrease in the flow of stool.Central nervous system diseasesA few diseases of the brain and spinal cord may cause constipation, including Parkinson's disease, multiple sclerosis, and spinal cord injuries.Colonic inertiaColonic inertia is a condition in which the nerves and/or muscles of the colon do not work normally. As a result, the contents of the colon are not propelled through the colon normally. The cause of colonic inertia is unclear. In some cases, the muscles or nerves of the colon are diseased. Colonic inertia also may be the result of the chronic use of stimulant laxatives as described above. In most cases, however, there is no clear cause for the constipation.Pelvic floor dysfunctionPelvic floor dysfunction (also known as outlet obstruction or outlet delay) refers to a condition in which the muscles of the lower pelvis that surround the rectum (the pelvic floor muscles) do not work normally. These muscles are critical for defecation (bowel movement). It is not known why these muscles fail to work properly in some people, but they can make the passage of stools difficult even when everything else is normal.How is constipation evaluated?A careful history and physical examination is important in all patients with constipation. There are many tests that can be used to evaluate constipation. Most patients need only a few basic tests. The other tests are reserved for individuals who have severe constipation or whose constipation does not respond easily to treatment.Medical HistoryA careful medical history from a patient with constipation is critical for many reasons, but particularly because it allows the physician to define the type of constipation. This, in turn, directs the diagnosis and treatment. For example, if defecation is painful, the physician knows to look for anal problems such as a narrowed anal sphincter or an anal fissure. If small stools are the problem, there is likely to be a lack of fiber in the diet. If the patient is experiencing significant straining, then pelvic floor dysfunction is likely.The history also uncovers medications and diseases that can cause constipation. In these cases, the medications can be changed and the diseases can be treated.A careful dietary history-which may require keeping a food diary for a week or two-can reveal a diet that is low in fiber and may direct the physician to recommend a high-fiber diet. A food diary also allows the physician to evaluate how well a patient increases his dietary fiber during treatment.Physical examinationA physical examination may identify diseases (for example, scleroderma) that can cause constipation. A rectal examination with the finger may uncover a tight anal sphincter that may be making defecation difficult. If a stool-filled colon can be felt through the abdominal wall, it suggests that constipation is severe. Stool in the rectum suggests a problem with the anal, rectal, or pelvic floor muscles.Blood testsBlood tests may be appropriate in evaluating patients with constipation. More specifically, blood tests for thyroid hormone (to detect hypothyroidism) and for calcium (to uncover excess parathyroid hormone) may be helpful.Abdominal X-rayLarge amounts of stool in the colon usually can be visualized on simple X-ray films of the abdomen; the more stool that is visualized, the more severe the constipation.Barium enemaA barium enema (lower GI series) is an x-ray study in which liquid barium is inserted through the anus to fill the rectum and colon. The barium outlines the colon on the X-rays and defines the normal or abnormal anatomy of the colon and rectum. Tumors and narrowings (strictures) are among the abnormalities that can be detected with this test.Colonic transit (marker) studiesColonic transit studies are simple X-ray studies that determine how long it takes for food to travel through the intestines. For transit studies, individuals swallow capsules for one or more days. Inside the capsules are many small pieces of plastic that can be seen on X-rays. The gelatin capsules dissolve and release the plastic pieces into the small intestine. The pieces of plastic then travel (as would digesting food) through the small intestine and into the colon. After 5 or 7 days, an X-ray of the abdomen is taken and the pieces of plastic in the different parts of the colon are counted. From this count, it is possible to determine if and where there is a delay in the colon. In non-constipated individuals, all of the plastic pieces are eliminated in the stool and none remain in the colon. When pieces are spread throughout the colon, it suggests that the muscles and/or nerves throughout the colon are not working, which is typical of colonic inertia. When pieces accumulate in the rectum, it suggests pelvic floor dysfunction.DefecographyDefecography is a modification of the barium enema examination. For this procedure, a thick paste of barium is inserted into the rectum of a patient through the anus. X-rays then are taken while the patient defecates the barium. The barium clearly outlines the rectum and anus and demonstrates the changes taking place in the muscles of the pelvic floor during defecation. Thus, defecography examines the process of defecation and provides information about anatomical abnormalities of the rectum and pelvic floor muscles during defecation.Ano-rectal motility studiesAno-rectal motility studies, which complement defecography tests, provide an assessment of the function of the muscles and nerves of the anus and rectum. For ano-rectal motility studies, a flexible tube, approximately an eighth of an inch in diameter, is inserted through the anus and into the rectum. Sensors within the tube measure the pressures that are generated by the muscles of the anus and rectum. With the tube in place, the patient performs several simple maneuvers such as voluntarily tightening the anal muscles. Ano-rectal motility studies can help determine if the muscles of the anus and rectum are working normally. When the function of these muscles is impaired, the flow of stool is obstructed, thereby causing a condition similar to pelvic floor dysfunction.Colonic motility studiesColonic motility studies are similar to ano-rectal motility studies in many aspects. A very long, narrow (one-eighth inch in diameter), flexible tube is inserted through the anus and passed through part or all of the colon during a procedure called colonoscopy. Sensors within the tube measure the pressures that are generated by the contractions of the colonic muscles. These contractions are the result of coordinated activity of the colonic nerves and muscles. If the activity of the nerves or muscles is abnormal, the pattern of colonic pressures will be abnormal. Colonic motility studies are most useful in defining colonic inertia. These studies are considered research tools, but they can be helpful in making decisions regarding treatment in patients with severe constipation.What treatments are available for constipation?There are many treatments for constipation, and the best approach relies on a clear understanding of the underlying cause.Dietary fiber (bulk-forming laxatives)The best way of adding fiber to the diet is increasing the quantity of fruits and vegetables that are eaten. This means a minimum of five servings of fruits or vegetables every day. For many people, however, the amount of fruits and vegetables that are necessary may be inconveniently large or may not provide adequate relief from constipation. In this case, fiber supplements can be useful.Fiber is defined as material made by plants that is not digested by the human gastrointestinal tract. Fiber is one of the mainstays in the treatment of constipation. Many types of fiber within the intestine bind to water and keep the water within the intestine. The fiber adds bulk (volume) to the stool and the water softens the stool.There are different sources of fiber and the type of fiber varies from source to source. Types of fiber can be categorized in several ways, for example, by their source. The most common sources of fiber include:fruits and vegetables, wheat or oat bran, psyllium seed (for example, Metamucil, Konsyl), synthetic methyl cellulose (for example, Citrucel), and polycarbophil (for example, Equilactin, Konsyl Fiber).Polycarbophil often is combined with calcium (for example, Fibercon). However, in some studies, the calcium-containing polycarbophil was not as effective as the polycarbophil without calcium. A lesser known source of fiber is an extract of malt (for example, Maltsupex); however, this extract may soften stools in ways other than increasing fiber.Increased gas (flatulence) is a common side effect of high-fiber diets. The gas occurs because the bacteria normally present within the colon are capable of digesting fiber to a small extent. The bacteria produce gas as a byproduct of their digestion of fiber. All fibers, no matter what their source, can cause flatulence. However, since bacteria vary in their ability to digest the various types of fiber, the different sources of fiber may produce different amounts of gas. To complicate the situation, the ability of bacteria to digest one type of fiber can vary from individual to individual. This variability makes the selection of the best type of fiber for each person (for example, a fiber that improves the quality of the stool without causing flatulence) more difficult. Thus, finding the proper fiber for an individual becomes a matter of trial and error.The different sources of fiber should be tried one by one. The fiber should be started at a low dose and increased every one to two weeks until either the desired effect on the stool is achieved or troublesome flatulence interferes. (Fiber does not work overnight.) If flatulence occurs, the dose of fiber can be reduced for a few weeks and the higher dose can then be tried again. (It generally is said that the amount of gas that is produced by fiber decreases when the fiber is ingested for a prolonged period of time; however, this has never been studied.) If flatulence remains a problem and prevents the dose of fiber from being raised to a level that affects the stool satisfactorily, it is time to move on to a different source of fiber.When increasing amounts of fiber are used, it is recommended that greater amounts of water be consumed (for example, a full glass with each dose). Presumably, the water prevents "hardening" of the fiber and blockage (obstruction) of the intestine. This seems like simple and reasonable advice. However, ingesting larger amounts of water has never been shown to have any beneficial effect on constipation, with or without the addition of fiber. (There is already a lot of water in the intestine and extra water is absorbed and excreted in the urine.) It is reasonable to drink enough fluids to prevent dehydration because with dehydration there may be reduced intestinal water.Because of concern about obstruction, persons with narrowings (strictures) or adhesions (scar tissue from previous surgery) of their intestines should not use fiber unless it has been discussed with their physician. Some fiber laxatives contain sugar, and patients with diabetes may need to select sugar-free products.Lubricant laxativesLubricant laxatives contain mineral oil as either the plain oil or an emulsion (combination with water) of the oil. The oil stays within the intestine, coats the particles of stool, and presumably prevents the removal of water from the stool. This retention of water in the stool results in softer stool. Mineral oil generally is used only for the short-term treatment of constipation since its long-term use has several potential disadvantages. The oil can absorb fat-soluble vitamins from the intestine and, if used for prolonged periods, may lead to deficiencies of these vitamins. This is of particular concern in pregnancy during which an adequate supply of vitamins is important for the fetus. In the very young or very elderly in whom the swallowing mechanism is not strong or is impaired by strokes, small amounts of the swallowed oil may enter the lungs and cause a type of pneumonia called lipid pneumonia. Mineral oil also may decrease the absorption of some drugs such as warfarin (Coumadin) and oral contraceptives, thereby decreasing their effectiveness. Despite these potential disadvantages, mineral oil can be effective when short-term treatment is necessary.Emollient laxatives (stool softeners)Emollient laxatives are generally known as stool softeners. They contain a compound called docusate (for example, Colace). Docusate is a wetting agent that improves the ability of water within the colon to penetrate and mix with stool. This increased water in the stool softens the stool. Studies, however, have not shown docusate to be consistently effective in relieving constipation. Nevertheless, stool softeners often are used in the long-term treatment of constipation. It may take a week or more for docusate to be effective. The dose should be increased after one to two weeks if no effect is seen. Although docusate generally is safe, it may allow the absorption of mineral oil and some medications from the intestine. Absorbed mineral oil collects in tissues of the body, for example, the lymph nodes and the liver, where it causes inflammation. It is not clear if this inflammation has any important consequences, but it generally is felt that prolonged absorption of mineral oil should not be allowed. The use of emollient laxatives is not recommended together with mineral oil or with certain prescription medications. Emollient laxatives are commonly used when there is a need to soften the stool temporarily and make defecation easier (for example, after surgery, childbirth, or heart attacks). They are also used for individuals with hemorrhoids or anal fissures.Hyperosmolar laxativesHyperosmolar laxatives are undigestible, unabsorbable compounds that remain within the colon and retain the water that already is in the colon. The result is softening of the stool. The most common hyperosmolar laxatives are lactulose (for example, Kristalose), sorbitol, and polyethylene glycol (for example, MiraLax). and are available by prescription only. These laxatives are safe for long-term use and are associated with few side effects. Hyperosmolar laxatives may be digested by colonic bacteria and turned into gas, which may result in unwanted abdominal bloating and flatulence. This effect is dose-related and less with polyethylene glycol. Therefore, gas can be reduced by reducing the dose of the laxative. In some cases, the gas will decrease over time.Saline laxativesSaline laxatives contain non-absorbable ions such as magnesium, sulfate, phosphate, and citrate [for example, magnesium citrate (Citroma), magnesium hydroxide, sodium phosphate). These ions remain in the colon and cause water to be drawn into the colon. Again, the effect is softening of the stool. Magnesium also may have mild stimulatory effects on the colonic muscles. The magnesium in magnesium-containing laxatives is partially absorbed from the intestine and into the body. Magnesium is eliminated from the body by the kidneys. Therefore, individuals with impaired kidney function may develop toxic levels of magnesium from chronic (long duration) use of magnesium-containing laxatives. Saline laxatives act within a few hours. In general, potent saline laxatives should not be used on a regular basis. If major diarrhea develops with the use of saline laxatives and the lost fluid is not replaced by the consumption of liquids, dehydration may result. For constipation, the most frequently-used and mildest of the saline laxatives is milk of magnesia. Epsom Salt is a more potent saline laxative that contains magnesium sulfate.Stimulant laxativesStimulant laxatives cause the muscles of the small intestine and colon to propel their contents more rapidly. They also increase the amount of water in the stool, either by reducing the absorption of the water in the colon or by causing active secretion of water in the small intestine. The most commonly-used stimulant laxatives contain cascara (castor oil), senna (for example, Ex-Lax, Senokot), and aloe. Stimulant laxatives are very effective, but they can cause severe diarrhea with resulting dehydration and loss of electrolytes (especially potassium). They also are more likely than other types of laxatives to cause intestinal cramping. There is concern that chronic use of stimulant laxatives may damage the colon and worsen constipation, as previously discussed. Bisacodyl (for example, Dulcolax, Correctol) is a stimulant laxative that affects the nerves of the colon which, in turn, stimulate the muscles of the colon to propel its contents. Prunes also contain a mild colonic stimulant.Tegaserod (Zelnorm) Tegaserod (Zelnorm) was approved in 2002 by the FDA specifically for the treatment of abdominal pain and constipation in women with irritable bowel syndrome. In March of 2007, the FDA asked Novartis, the company manufacturing tegaserod, to suspend sales of tegaserod in the U.S. because a retrospective analysis of data by Novartis from more than 18,000 patients showed a slight difference in the incidence of cardiovascular events (heart attacks, strokes and angina) among patients taking tegaserod compared to placebo. The data showed that cardiovascular events occurred in 13 out of 11,614 patients treated with tegaserod (.11%), compared to one cardiovascular event in 7,031 (.01%) placebo-treated patients. However, it is unclear whether tegaserod actually causes heart attacks and strokes. Doctors and scientists will be scrutinizing the data to determine the long-term safety of tegaserod.The mechanism whereby tegaserod relieves constipation (and abdominal bloating and pain) is interesting and is related to its effects on the intestinal serotonin, a chemical that controls contractions of intestinal muscles. The contractions of the intestinal muscles control transit of digesting food through the intestine. More contractions speed transit, fewer contractions slow transit. In constipated patients, contractions are fewer. Serotonin is a chemical manufactured by nerves in the intestine that is released and then binds to muscle cells. Depending on which receptor it binds to on the muscle, serotonin can either promote or prevent contractions. The serotonin 5-HT4 receptor is a receptor that prevents contractions when serotonin binds to it. Tegaserod blocks the 5-HT4 receptor, prevents serotonin from binding to it, and thereby increases contractions of the intestinal muscles. The increased contractions speed the transit of digesting food and reduces constipation. In addition, tegaserod reduces the sensitivity of the intestinal pain-sensing nerves and can thereby reduce abdominal pain. In large placebo controlled trials involving men and women with chronic constipation, tegaserod was more effective than placebo in increasing the number of spontaneous bowel movements and reducing straining, abdominal bloating, abdominal pain, and abdominal discomfort. The most common side effect of tegaserod was diarrhea, which was usually mild or moderate and generally resolved within a few days while continuing treatment. Lubiprostone (Amitiza) Lubiprostone (Amitiza) is a selective chloride channel activator that increases secretion of chloride ions from the cells of the intestinal lining into the intestinal lumen. Sodium ions and water then follow the chloride ions into the lumen, and the water softens the stool. The FDA approved lubiprostone for the treatment of chronic constipation in both men and women in February 2006. At a dose of 24 micrograms twice a day, lubiprostone significantly and promptly increased bowel movements, improved stool consistency, and decreased straining. The most common side effect of initial clinical studies was mild to moderate nausea in 32% of patients treated with lubiprostone, compared to 3% of the controls. More long term studies of efficacy and side effects are needed to determine the place of lubiprostone in the treatment of constipation.EnemasThere are many different types of enemas. By distending the rectum, all enemas (even the simplest type, the tap water enema) stimulate the colon to contract and eliminate stool. Other types of enemas have additional mechanisms of action. For example, saline enemas cause water to be drawn into the colon. Phosphate enemas (for example, Fleet phosphosoda) stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stool. Emollient enemas (for example, Colace Microenema) contain agents that soften the stool.Enemas are particularly useful when there is impaction, which is hardening of stool in the rectum. In order to be effective, the instructions that come with the enema must be followed. This requires full application of the enema, appropriate positioning after the enema is instilled, and retention of the enema until cramps are felt. Defecation usually occurs between a few minutes and one hour after the enema is inserted.Enemas are meant for occasional rather than regular use. The frequent use of enemas can cause disturbances of the fluids and electrolytes in the body. This is especially true of tap water enemas. Soapsuds enemas are not recommended because they can seriously damage the rectum.SuppositoriesAs is the case with enemas, different types of suppositories have different mechanisms of action. There are stimulant suppositories containing bisacodyl (for example, Dulcolax). Glycerin suppositories are believed to have their effect by irritating the rectum. The insertion of the finger into the rectum when the suppository is placed may itself stimulate a bowel movement.Combination productsThere are many products that combine different laxatives. For example, there are oral products that combine senna and psyllium (Perdiem), senna and docusate (Senokot-S), and senna and glycerin (Fletcher's Castoria). One product even combines three laxatives, senna-like casanthranol, docusate, and glycerin (Sof-lax Overnight). These products may be convenient and effective, but they also contain stimulant laxatives. Therefore, there is concern about permanent colonic damage with the use of these products, and they probably should not be used for long-term treatment unless non-stimulant treatment fails. Miscellaneous drugsSeveral prescribed drugs that are used to treat medical diseases consistently cause (as a side effect) loose stools, even diarrhea. There actually are several small studies that have examined these drugs for the treatment of constipation.ColchicineColchicine is a drug that has been used for decades to treat gout. Most patients who take colchicine note a loosening of their stools. Colchicine has also been demonstrated to relieve constipation effectively in patients without gout.Misoprostol (Cytotec) Misoprostol (Cytotec) is a drug used primarily for preventing stomach ulcers caused by nonsteroidal antiinflammatory drugs such as ibuprofen. Diarrhea is one of its consistent side-effects. Several studies have shown that misoprostol is effective in the short term treatment of constipation. Misoprostol is expensive, and it is not clear if it will remain effective and safe with long-term use. Therefore, its role in the treatment of constipation remains to be determined.Orlistat (Xenical) Orlistat (Xenical) is a drug that is used primarily for reducing weight. It works by blocking the enzymes within the intestine that digest fat. The undigested fat is not absorbed, which accounts for the weight loss. Undigested fat is digested by bacteria within the intestine and the products of this bacterial digestion promote the secretion of water. The products of digestion also may affect the intestine in other ways, for example, by stimulating the intestinal muscles. In fact, in studies, orlistat has been shown to be effective in treating constipation. Orlistat has few important side effects, which is consistent with the fact that only very small amounts of the drug are absorbed from the intestine.It is unclear if these prescribed drugs should be used for the treatment of constipation. Although it is difficult to recommend them specifically just for the treatment of constipation, they might be considered for constipated individuals who are overweight, have gout, or need protection from nonsteroidal antiinflammatory drugs.ExercisePeople who lead sedentary lives are more frequently constipated than people who are active. Nevertheless, limited studies of exercise on bowel habit have shown that exercise has minimal or no effect on the frequency of bowel movements. Thus, exercise can be recommended for its many other health benefits, but not for its effect on constipation.BiofeedbackMost of the muscles of the pelvis surrounding the anus and rectum are under some degree of voluntary control. Thus, biofeedback training can teach patients with pelvic floor dysfunction how to make their muscles work more normally and improve their ability to defecate. During ano-rectal biofeedback training, a pressure-sensing catheter is placed through the anus and into the rectum. Each time a patient contracts the muscles, the muscles generate a pressure that is sensed by the catheter and recorded on a screen. By watching the pressures on the screen and attempting to modify them, patients learn how to relax and contract the muscles more normally.SurgeryFor individuals with problematic constipation that is due to diseases of the colon or laxative abuse, surgery is the ultimate treatment. During surgery, most of the colon, except for the rectum (or the rectum and part of the sigmoid colon), is removed. The cut end of the small intestine is attached to the remaining rectum or sigmoid colon. In patients with colonic inertia, surgery is reserved for those who do not respond to all other therapies. If the surgery is to be done, there must be no disease of the small intestinal muscles. Normal small intestinal muscles are evidenced by normal motility studies of the small intestine itself.Electrical pacingElectrical pacing is still in its experimental phases. Electrical pacing may be done using electrodes implanted into the muscular wall of the colon. The electrodes exit the colon and are attached to an electrical stimulator. Alternatively, stimulation of the sacral skin can be used to stimulate nerves going to the colon. These techniques are promising, but much more work lies ahead before their role in treating constipation, if any, has been defined.What is the approach to the evaluation and treatment of constipation?There are several principles in approaching the evaluation and treatment of constipation.The first principle is to differentiate between acute (recent onset) and chronic (long duration) constipation. Thus, with acute constipation or constipation that is worsening, it is necessary to assess for the cause early so as not to overlook a serious illness that should be treated urgently.The second principle is to start treatment early and use the treatments that have the least potential for harm. This will prevent constipation from worsening, and it also will prevent potential damage to the colon that can be caused by the frequent use of stimulant laxatives. The third principle is to know when it is time to evaluate the cause of chronic constipation. Evaluation for the cause of chronic constipation needs to be done if there is no response to the simple treatments.The goal of treatment in constipation should not be a bowel movement every day, but a bowel movement every two to three days without difficulty (without straining). Start with the simple things. Don't suppress urges to defecate. When the urge comes, find a toilet. With the assistance of your physician and pharmacist, determine if there are drugs that you are taking that could be contributing to the constipation. See if the drugs can be discontinued or changed. Increase the fiber in your diet by consuming more fruits, vegetables, and whole grains. (There are other health benefits from this recommendation as well.) It may be difficult to get enough fiber in the diet to effectively treat constipation, so don't hesitate to take fiber supplements if necessary (wheat bran, psyllium, etc.). Use increasing amounts of fiber and/or change the type of fiber consumed until there is a satisfactory result. Don't expect fiber to work overnight. Allow weeks for adequate trials.What if constipation does not respond to these simple, safe measures? These efforts should not be discontinued but other measures should be added. If the constipation is infrequent, that is, every few weeks (as it can be when due to the menstrual cycle), it probably doesn't matter what other measures are added-emollient, saline, or hyper-osmolar laxatives, enemas, and suppositories. Even stimulant laxatives every four to isx weeks are unlikely to damage the colon. Unfortunately, the tendency when using stimulant laxatives is to unconsciously increase the frequency of their use. Before you know it, you're taking them every week, or more often, and permanent damage might result.If constipation is a continuous rather than an intermittent problem, probably the safest laxatives to take on a regular basis are the hyper-osmolar laxatives. They require a prescription and, therefore, necessitate a call to a physician. As with fiber, increasing doses of different hyper-osmolar laxatives should be tried over several weeks until a satisfactory type and dose of laxative is found. Hyper-osmolar laxatives, however, can be expensive. Milk of magnesia is the mildest of the saline laxatives, is inexpensive, and provides a good alternative. Most patients can adjust the dose of milk of magnesia to soften the stool adequately without developing diarrhea or leakage of stool.Prunes and prune juice have been used for many years to treat mild constipation. There is no evidence that the mild stimulant effects of prunes or prune juice damage the colon. Stronger stimulant laxatives usually are recommended only as a last resort after non-stimulant treatments have failed. Many people take herbs to treat their constipation because they feel more comfortable using a "natural" product. Unfortunately, most of these herbal preparations contain stimulant laxatives and their long term use raises the possibility that they also may damage the colon.When should I seek medical care for chronic constipation?If the main problem is straining to push the stool out, chronic constipation should probably be evaluated early. This difficulty might be due to pelvic floor dysfunction, and the treatment of choice is biofeedback training, not laxatives. If the constipation is not responding to the simple measures discussed previously with the addition of hyper-osmolar laxatives or milk of magnesia, it is time to consult a physician for an evaluation. If a primary doctor is not comfortable performing the evaluation or does not have confidence in doing an evaluation, he or she should refer the patient to a gastroenterologist. Gastroenterologists evaluate constipation frequently and are very familiar with the diagnostic testing described previously.What's new in the treatment of constipation?Each part of the intestine (stomach, small intestine, and colon) has a network of nerves that controls its muscles. A great deal of research is being done in order to gain an understanding of how these nerves control each other and ultimately the muscles. Much of this research involves the study of neurotransmitters. (Neurotransmitters are chemicals that nerves use to communicate with each other.) This research is allowing scientists to develop drugs that stimulate (and inhibit) the various nerves of the colon which, in turn, cause the muscles of the colon to contract and propel the colonic contents. Such drugs have great potential for the treatment of constipation that is due to colonic inertia. The first of these drugs is in clinical trials and is likely to be available soon. These drugs are an exciting development because they offer a new treatment for a difficult-to-treat form of constipation. Nevertheless, there are many questions about these types of drugs that must be answered. How effective are they? Will they work in many or only a few patients? Will they work in patients who have damaged their nerves with stimulant laxatives? Since these medications are likely to be used for a lifetime, how safe will they be with many years of use? Will they be used indiscriminately in situations for which simple treatments (for example, fiber) or more appropriate treatments (for example, biofeedback training) should be used?Constipation At A GlanceConstipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week. Constipation usually is caused by the slow movement of stool through the colon. There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon. The two disorders limited to the colon that cause constipation are colonic inertia and pelvic floor dysfunction. Medical evaluation for the cause of constipation should be done when constipation is of sudden onset, severe, worsening, associated with other worrisome symptoms such as loss of weight, or is not responding to simple, safe treatments. Medical evaluation of constipation may include a history, physical examination, blood tests, abdominal X-rays, barium enema, colonic transit studies, defecography, ano-rectal motility studies, and colonic motility studies. The goal of therapy for constipation is one bowel movement every two to three days without straining. Treatment of constipation may include dietary fiber, non-stimulant laxatives, stimulant laxatives, enemas, suppositories, biofeedback training, and surgery. Stimulant laxatives should be used as a last resort because of the possibility that they may permanently damage the colon and worsen constipation. Most herbal laxatives contain stimulant-type laxatives and should be used, if at all, as a last resort.When should I seek medical care for chronic constipation?If the main problem is straining to push the stool out, chronic constipation should probably be evaluated early. This difficulty might be due to pelvic floor dysfunction, and the treatment of choice is biofeedback training, not laxatives. If the constipation is not responding to the simple measures discussed previously with the addition of hyper-osmolar laxatives or milk of magnesia, it is time to consult a physician for an evaluation. If a primary doctor is not comfortable performing the evaluation or does not have confidence in doing an evaluation, he or she should refer the patient to a gastroenterologist. Gastroenterologists evaluate constipation frequently and are very familiar with the diagnostic testing described previously.What's new in the treatment of constipation?Each part of the intestine (stomach, small intestine, and colon) has a network of nerves that controls its muscles. A great deal of research is being done in order to gain an understanding of how these nerves control each other and ultimately the muscles. Much of this research involves the study of neurotransmitters. (Neurotransmitters are chemicals that nerves use to communicate with each other.) This research is allowing scientists to develop drugs that stimulate (and inhibit) the various nerves of the colon which, in turn, cause the muscles of the colon to contract and propel the colonic contents. Such drugs have great potential for the treatment of constipation that is due to colonic inertia. The first of these drugs is in clinical trials and is likely to be available soon. These drugs are an exciting development because they offer a new treatment for a difficult-to-treat form of constipation. Nevertheless, there are many questions about these types of drugs that must be answered. How effective are they? Will they work in many or only a few patients? Will they work in patients who have damaged their nerves with stimulant laxatives? Since these medications are likely to be used for a lifetime, how safe will they be with many years of use? Will they be used indiscriminately in situations for which simple treatments (for example, fiber) or more appropriate treatments (for example, biofeedback training) should be used?Constipation At A GlanceConstipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week. Constipation usually is caused by the slow movement of stool through the colon. There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon. The two disorders limited to the colon that cause constipation are colonic inertia and pelvic floor dysfunction. Medical evaluation for the cause of constipation should be done when constipation is of sudden onset, severe, worsening, associated with other worrisome symptoms such as loss of weight, or is not responding to simple, safe treatments. Medical evaluation of constipation may include a history, physical examination, blood tests, abdominal X-rays, barium enema, colonic transit studies, defecography, ano-rectal motility studies, and colonic motility studies. The goal of therapy for constipation is one bowel movement every two to three days without straining. Treatment of constipation may include dietary fiber, non-stimulant laxatives, stimulant laxatives, enemas, suppositories, biofeedback training, and surgery. Stimulant laxatives should be used as a last resort because of the possibility that they may permanently damage the colon and worsen constipation. Most herbal laxatives contain stimulant-type laxatives and should be used, if at all, as a last resort.
肛肠手术围手术期处理及注意事项1术前1.1病人应当如实汇报病史,如高血压;糖尿病;心脏病;出血病史;特别是目前有无口服华法令,阿司匹林等影响血凝的药物应用,因为口服药物期间手术,可明显增加术中出血,术后出血的发生率比较高,应当停止药物1周后,再考虑手术。有高血压心脏病的病人手术中及手术后发病的几率大于平时;糖尿病的病人手术后容易感染;血友病的病人术中和术后会出现出血不止,需特殊处理才能止血。2.2术前应当清洁肠道,排出肠道内的粪便,这有利于手术后早期内(2天内)不用排便,减少疼痛和引起出血的可能性。清洁肠道有两种方法:一是口服泻药,二是灌肠。对于肛裂肛周脓肿,血栓性痔等肛门疼痛的疾病最好应用口服药清洁肠道,但是需要从上午开始口服药物,同时口服2000ml温开水,要在1.5小时内喝完,中午就不能再进饮食,泄完水样便后2小时后才可手术,需要给肠道一个吸收水分的时间,因此口服清洁肠道药物共计需要约5小时左右。比如下午3点手术,上午10点就得开始准备。灌肠较快,但是不如口服泻药干净。2术后2.1我们术中基本上使用骶管麻醉,骶管麻醉具有麻醉完全,肛门松弛好,手术到位效果好的特点。但是也有其不利的方面,有1/4的病人出现下肢无力,不能行走。不过不用担心,一般6小时后就能恢复。骶麻的另一个不利方面是术后尿潴留,即不能排尿,因此我们要求术后第一次小便之前不要吃饭和饮水,输液速度要慢,6小时后可站立排尿,这样可以明显减少尿潴留的发生率,实在不能排尿就要需要导尿,需要导尿的人大约占1/10.2.2饮食方面:第一次排尿后可以随便饮水,当晚可进食少量米汤类流食,第二天开始以流食为主,这样食物残渣少,可明显延长手术到第一次大便的时间,有利于减少大便引起的刀口出血,疼痛,感染等。第三天开始普通饮食。2.3手术后可出现小便发蓝色,是因为我们术后应用了长效止痛药物,小便会逐渐变为正常颜色,不用担心。2.4手术后,麻醉效果消失后,可能出现肛门轻微疼痛,壅塞感,感觉好像是有大便,这时不要去排便,因为这是我们手术后在肛门里放置了引流管,放引流管的目的是为了容易排气,观察有无内出血的情况(手术后出血大部分流向直肠,肛门外观察不到),因此不要去大便,更不能随意取出,因为排气管外包绕纱布起到压迫止血的作用,一旦取出发生较为严重的出血,在无麻醉的情况下是不可能止血的,需要重新麻醉止血,增加了手术后的不安全性。有1/20的病人不听大夫劝告,私自取出或蹲厕所,事实上蹲厕所也没有大便出来,因为我们已经术前灌肠,哪里会有大便?一定要配合医生。2.5我们手术后的病人,疼痛较轻,极少数病人,疼觉过敏,需要止痛药物,约占1/20.2.6对于痔疮术后的病人,特别是内痔套扎的病人术后肛管取出后开始口服石蜡油,40ml每天,有利于大便较软,排便通畅,防止较长时间的蹲便,及过度用力。使手术切口边缘发生水肿,时间长了会形成皮垂,或其它部位又出现痔疮。内痔套扎后,应当让其结扎线自然脱落,如果大便干硬,会使结扎线过早脱落,引起出血,正常一般在5-7天自然脱落。2.7对于肛裂的病人,术后可让大便干硬一些,因此不用服石蜡油,干硬的大便对肛管有进一步的扩张作用,延缓刀口愈合,防止肛门过早愈合再度狭窄。2.8术后第三天开始中药熏洗,中药熏洗能够去腐生肌,活血化瘀,促进刀口愈合的作用。2.9除了内痔套扎之外,肛周大部分有切口,大约30天左右才能愈合,在愈合之前,会有渗液。应当每天1/5000高锰酸钾温水坐浴,坐浴后沾干,局部应用痔疮膏类药物,肛门夹一块纱布有利于吸收创口的渗液,同时换纱布时带走坏死组织和分泌物。 衷心希望您了解各项治疗措施,配合医生治疗。 祝您早日恢复健康
否。 根据目前的肛垫下移学说,正常大便时肛垫下移送出大便,便后肛垫自然回缩复位,如果不能回位,齿线以下肛垫脱出称为外痔,齿线以上肛垫脱出称为内痔。齿线上下肛垫都脱出称为混合痔。肛垫具有重要的生理功能,能够分辨气体还是液体,是能够自然封闭肛门的弹性垫,如果整个肛垫被切除,肛门会出现失禁,不能分辨液体还是气体,因此,治疗痔疮的原则是只处理有病变的组织即脱出或出血的组织,其它组织不予处理。那么其它组织以后会不会再发生病理性脱出哪?不注意肛门卫生和饮食及排便习惯,痔疮以后照样会发生,因此痔疮不能根治,也不应当根治。
否。肛瘘一定得手术治疗 肛瘘一般由于肛门直肠周围脓肿溃破或切开后伤口迁延不愈,脓腔缩小,腔壁结缔组织增生,形成直的或弯的管道,常有位于肠内的内口和位于肛门外的外口。表现为肛周流脓、疼痛、肛周分泌物刺激而搔痒等。肛瘘在不同阶段可有不同表现,静止期瘘道引流通畅,炎症消退,可无症状或只有轻度不适,给人以痊愈的错觉。其实肛瘘形成后病灶并未去除,常常时愈时发,反复发作,甚至再次形成脓肿,使瘘管走行复杂,成为复杂性肛瘘,形成多个外口,增加治疗难度,不能自愈。所以一旦确诊为肛瘘,就一定要手术。肛瘘属难治性疾病,困难在于即要治好病又要尽可能保护肛门括约功能。我们根据瘘管深浅、复杂性、范围、曲直采取切开、缝合、挂线、虚挂线疗法、潜行瘘管切除、旷置等方法治疗肛瘘,取得了较好的疗效。
低位长窦道肛瘘潜行切除术后潜行瘘管切除术治疗低位长瘘道肛瘘48例分析刘光生 康宗益 张耀中山东省蓬莱市中医院外科摘要 目的:探讨潜行瘘管切除术治疗低位长瘘道肛瘘的临床效果。方法:将肛瘘外口至肛缘距离大于5cm的低位单纯性肛瘘分为两组:治疗组应用潜行瘘管挖出的方法,对照组应用传统的漏管切开的方法。比较两组病例治愈时间;肛门变形 复发率。结果:实验组48例病人痊愈,随访一年无复发,平均愈合时间12天,无肛门变形,无肛门失禁。对照组42例:平均愈合时间23天,肛门变形23例,控制气体能力减弱12例。结论:潜行瘘管切除术治疗低位长瘘道肛瘘愈合时间短,肛门不变形,痛苦小,复发率与对照组无显著差异。关键词:肛瘘;瘘管切除术Analyze 48cases of Subcutanous fistula excision for the treatment of long-path low anus fistula Liuguangsheng Kangzongyi ZhangyaozhongColorectal surgery of Binzhou central hospital Shandong province ChinaAbstract Objective to investigate the clinical effectiveness of subcutanous fistula excision for the long-path low anus fistula.Methods operation for long-path low anus fistula,fistula length >5cm,divided the patients into two groups .the expermental group : use subcutanous fistula excision;the conventional group:use fistula icision.compare the healing time ;anus malformation ;recurrence rate.Rusult experimental group 48cases heal,the healing time was 12days ;no anus malformation; no anus incontenience.the conventional group the healing time was 23days ;anus malformation23cases; anus gas incontenience 12.Conclusion to use subcutanous fistula excision for the long-path low anus fistula has the advantagements of short healing time ,no anus malformation ,less pain.and has no statistic diffrences in reccurrent rates.Key words anus fistula; fistula excision.1资料与方法 1.1临床资料 治疗组:男性30例,女性18例;高位复杂性肛瘘9例,低位单纯性肛瘘39例;年龄最大68岁,最小20岁,平均35岁。 对照组42 例 男性36例,女性6例;高位复杂性肛瘘5例,低位单纯性肛瘘37例;年龄最大70岁,最小19岁,平均34岁。两组资料无统计学差异。 1.2手术方法:术前常规瘘道造影了解瘘道行程,有无支管及腔隙,有无内口。对多瘘道肛瘘术前常规行电子结肠镜检查,术前清洁灌肠,应用骶管麻醉,左侧或右侧卧位。局部消毒,待麻醉起效后作肛内外探查,包括内口位置、硬索走向及起止点等。首先将瘘管内注入美兰,围绕漏管外口一周切开,用鼠齿钳提起,在瘘管周围疏松的皮下组织中游离。若瘘管经过小部分肛门外括约肌,可将瘘管浅层肌束切断,有利于充分显露瘘管。若有内口可一直切到内口周围粘膜,将整条瘘管切除,然后将内口粘膜用可吸收缝线缝合。若无内口,可将染色的组织全部切除为止,注意在剥切过程中不能剪破上方覆盖组织,特别是内口闭合处,不要人造内口。若瘘管上段经过大部分肛门括约肌并且位置高,可在肛管另做一切口,其将分离出的瘘管切除,高处挂线。高处若有支管,也用远处瘘管潜行切除,高处分别挂线。术后换药, 术后禁便48小时,排便后用1/5000高锰酸钾温水坐浴20分钟。每日换药1~2次,用红油膏纱条在疮面底部填塞,既使疮面肉芽从底部向外生长,又起到腔内引流作用。腔隙变浅后,可酌情改用三石散油膏等外用,直至疮面痊愈。2结果: 48例病人痊愈,随访一年无复发,一例病人一年内再发肛周脓肿,行切开挂线治疗,一个月后治愈。平均愈合时间12天,无肛门变形,无肛门失禁。对照组:平均愈合时间23天,肛门变形23例,控制气体能力减弱12。两组结果有显著性差异。3讨论: 传统的瘘管切开术,特别是长的肛瘘,切开后创面大,愈合时间长,患者痛苦大,肛门容易变形。因此尽量想办法,保留瘘管浅面的皮肤和皮下组织,减小创面。能保留多少就保留多少。 在多年肛瘘手术中发现,有较多病例用银丝探针并未能从病变内口处直接穿出,而常见有一层薄薄的粘膜隔阻,需稍稍用力才能穿出,说明内口处在损伤后容易修复而呈阶段性闭锁状态,并非长期呈溃口状态,这也许可以解释肛瘘发作存在间歇期的原因。由此不难理解,当内口处于闭合状态时,只要有一种既能清除瘘管组织,又能使内口处于永久性闭合状态的手术方法就能治愈肛瘘。本“瘘道潜行切除法”(1)就具备上述两个功能,随着内口下方瘘管硬索的潜行切除,肛腺导管和肛腺因共存于瘘管组织中而被同时切除,由此内口处即会因废用性萎缩而呈永久性闭合状态。低位长距离肛瘘采用本法,则保存了正常的肛管皮肤组织,术后肛门无豁口、不变形,保证了肛管的各项正常功能,对肛门自制有着十分重要的意义;又因排便时粪便不直接刺激、污染创面,故术后痛苦少。 确定肛瘘的病因十分重要,特别是复杂性肛瘘,要警惕原发性炎性肠病(Crohn\"s disease)(2)。对于炎性肠病应当以引流和内科治疗为主,尽可能保护括约肌功能和肛门完整性。对于复杂的肛瘘应当在麻醉起效后进一步详细检查瘘管的行程,应当根据具体情况采取不同的个体化治疗方案。Goodsall\"s 规则有一定帮助,外开口在肛门中线之前的瘘管一般较直,短;开口位于肛门中线后侧的肛瘘一般是弧形的瘘管(2)。在瘘管切除时应始终牢记,肛门后外侧的手术有可能损伤支配括约肌的阴部神经,特别是较深的切开(2)。参考文献:1潘友珍 马志康 “隧道切除法”治疗肛瘘36例 上海中医药杂志2000年 第34卷 第4期 422 Ira J. Kodner, M.D Anal Procedures for Benign Disease: Introduction From ACS Surgery Online Posted 06/07/2006